Fibrotic encapsulation of orthodontic appliance in palate.

Iatrogenic trauma though not serious is very common in dental practice. Orthodontic treatment can inflict such injuries as they are prolonged over a long period of time. Ill-fabricated orthodontic appliances, such as wires and brackets, or the patients' habits such as application of constant pressure over the appliance can traumatize the adjacent oral soft tissues. In rare cases, these appliances can get embedded into the mucosa and gingival tissues. This case report describes one such case of iatrogenic trauma to the palatal mucosa due to entrapment of a tongue spike appliance and its surgical management.

INTRODUCTION

Iatrogenic injuries are defined as any trauma that is induced by dentist's manner of therapy.[1] Orthodontic treatment is one of the common causes for iatrogenic trauma of the gingiva. Orthodontic appliances such as wires and brackets can traumatize oral soft tissues including tongue and gingiva. In rare cases, they can get embedded into the mucosal and gingival tissues.[2] This article reports a rare case of iatrogenic trauma to the palatal mucosa due to entrapment of tongue spike appliance.

CASE REPORT

A 20-year-old male patient was referred from the Department of Orthodontics for removal of tongue spike appliance. The patient had been having the appliance for the past 2 years throughout the fixed orthodontic treatment. The orthodontic treatment was done in a private practice. On intraoral examination, the appliance was found to be entrapped in the palatal mucosa [Figure 1a]. On history, the patient had been having the appliance for the past 2 years.

Figure 1

(a) Entrapped appliance in the palate. (b) Surgical removal of appliance. (c) The removed appliance with tissue. (d) Sutures placed. (e) One-month postoperative. (f) Histopathology

Case management

The appliance was resistant to removal by conventional means. The components of the tongue spike were found to be embedded firmly into the palatal mucosa. The area exhibited no ulceration, bleeding, nor did the patient have any pain or discomfort. The treatment was explained to the patient and consent was obtained. The appliance was cut into smaller components and then removed surgically [Figure 1b and c]. Considerable amount of fibrous tissue was excised to relieve the appliance completely, suggesting that embedded part of the appliance was encapsulated in a fibrous mass of tissue. The tissue was relatively firmer in consistency than the palatal gingiva. The tissue was sent for histopathological analysis. Simple interrupted sutures were placed to approximate the wound [Figure 1d]. The patient was recalled after a week and sutures were removed. The healing was satisfactory. A recall was done after a month and healing was uneventful and no scar was evident [Figure 1e].

Histopathological analysis

The photomicrograph of hematoxylin and eosin section of the excised tissue revealed shortened stratified squamous epithelium. The connective tissue exhibited interlacing networks of collagen fibers [Figure 1f]. Based on this, the tissue was considered as fibroma. Considering the clinical data, diagnosis of traumatic fibroma was given.

DISCUSSION

Injuries to oral tissues may be accidental, iatrogenic, or factitious.[3] Iatrogenic trauma to gingiva can be either physical or chemical. Trauma to gingiva following orthodontic treatments is mainly physical. The most common manifestations are gingival recession and ulcerations.[4]

Physical injuries to gingiva during orthodontic treatment are due to ill-fabricated prosthesis. In the present case, the tongue crib was fabricated too short. This succumbed to upward pressure from the tongue during mastication, speech, or habitual action and forced the appliance into encapsulation in the palate. The appliance was surgically removed with a considerable amount of highly fibrous tissue attached to it.

On histological examination, the tissue was diagnosed as traumatic fibroma. The appliance served as source of constant irritation that resulted in fibrotic hyperplasia of the surrounding tissues that encapsulated the appliance eventually.[5] Hence, careful fabrication of appliance is of utmost importance to avoid such problems. Appliance should be fabricated in such a way that the metal crib extends 2–3 mm beyond the incisal edge. This will prevent upward pushing of the appliance by the tongue. In addition, the patient must also be informed about the expected complications and need for regular check-up appointments to monitor the relation of appliance with surrounding tissues.

Severity of involvement of the periodontal tissues determines the management of such traumatic lesions. In most of the cases, elimination of the etiology will do, whereas in severe cases, surgical intervention becomes necessary.[6] Orthodontics though improves dental function and esthetics can also cause unwanted complications if adequate care is not implemented.[7]

CONCLUSION

Most of the adverse effects of orthodontic treatment can be easily avoided by undertaking necessary precautions during the treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.